A War Inside: Saving Veterans from Suicide

PHILADELPHIA — An estimated 18 American military veterans take their own lives every day -- thousands each year -- and those numbers are steadily increasing. Even after weathering the stresses of military life and the terrors of combat, these soldiers find themselves overwhelmed by the transition back into civilian life. Many have already survived one suicide attempt, but never received the extra help and support they needed, with tragic results. A team of researchers from the Perelman School of Medicine at the University of Pennsylvania and colleagues found that veterans who are repeat suicide attempters suffer significantly greater mortality rates due to suicide compared to both military and civilian peers. The research was published this month in BMC Public Health.

The study is the largest follow-up of suicide attempters in any group in the United States, and is unique even among the relatively few studies on veteran suicide: "We looked at suicide among veterans who had already attempted suicide one time," notes study author Douglas J. Wiebe, PhD, assistant professor of Epidemiology. The findings, he says, "should have us very concerned about current veterans in the more contemporary era."

Wiebe, along with Janet Weiner of Penn's Leonard Davis Institute of Health Economics and Therese S. Richmond of the School of Nursing, teamed with Joseph Conigliaro of the New York University School of Medicine to conduct a study of military veterans who received inpatient treatment at a Department of Veterans Affairs (VA) medical center for a suicide attempt between 1993 and 1998. Using additional data from the VA, as well as the National Center of Health Statistics, these veterans were followed for incidence, rate, and cause of mortality through the end of 2002.

Among the total of 10,163 veterans treated for a suicide attempt between 1993-1998, 1,836 died during the follow-up period through 2002, with heart disease, cancer, accidents, and suicide accounting for over 57% of those deaths. Suicide, however, was the second- leading cause of death among the male veterans, and the leading cause among females, accounting for just over 13% of all the deaths in the study cohort. In comparison, suicide accounted for only 1.8% of deaths in the general U.S. population during those years.

Wiebe and his colleagues discovered that veterans who have attempted suicide not only have an elevated risk of further suicide attempts, but face mortality risks from all causes at a rate three times greater than the general population. The so-called "healthy soldier effect," that military personnel should be healthier than an average person of the same sex and age because they have passed military fitness requirements, does not protect veterans from death from chronic disease, and does not appear to mitigate their risk of suicide. "The 'healthy soldier effect' is no reason to think that veterans should be more emotionally and mentally resilient than anyone else," says Wiebe. "The consequences of military service can include both physical and emotional health challenges that veterans continue to face long after their 'war' is no longer on the front page."

The current study strongly emphasizes the increased need for more intensive and vigorous efforts to identify and support veterans who are at risk, especially those who have already actually attempted suicide, say the authors. With military personnel now facing combat in numbers not seen since the Vietnam War, developing better strategies for suicide prevention is more important than ever. "Almost all of today's soldiers are seeing combat and repeated tours, so that could be a reason to be even more concerned about veteran populations in the years moving forward," Wiebe says.

Wiebe's next step is to analyze the collected data to identify more specific risk factors for suicide or other premature causes of death. Although he argues that "we need to be more tuned into this problem in America in general," he is hopeful that examples of successful suicide prevention programs, particularly one conducted by the U.S. Air Force, could provide an inspiration and foundation for new efforts. "A major part of the success of that program was just changing the climate around how people think and talk about suicide," he says. "There's evidence out there to suggest that could work among veterans too. The time to get started is now."

The Perelman School of Medicine has been ranked among the top five medical schools in the United States for the past 17 years, according to U.S. News & World Report's survey of research-oriented medical schools. The School is consistently among the nation's top recipients of funding from the National Institutes of Health, with $392 million awarded in the 2013 fiscal year.

The University of Pennsylvania Health System's patient care facilities include: The Hospital of the University of Pennsylvania -- recognized as one of the nation's top "Honor Roll" hospitals by U.S. News & World Report; Penn Presbyterian Medical Center; Chester County Hospital; Penn Wissahickon Hospice; and Pennsylvania Hospital -- the nation's first hospital, founded in 1751. Additional affiliated inpatient care facilities and services throughout the Philadelphia region include Chestnut Hill Hospital and Good Shepherd Penn Partners, a partnership between Good Shepherd Rehabilitation Network and Penn Medicine.

Penn Medicine is committed to improving lives and health through a variety of community-based programs and activities. In fiscal year 2013, Penn Medicine provided $814 million to benefit our community.